Cluster randomized trial of a toolkit and early vaccine delivery to improve childhood influenza vaccination rates in primary care.

PURPOSE: To increase childhood influenza vaccination rates using a toolkit and early vaccine delivery in a randomized cluster trial. METHODS: Twenty primary care practices treating children (range for n=536-8183) were randomly assigned to Intervention and Control arms to test the effectiveness of an evidence-based practice improvement toolkit (4 Pillars Toolkit) and early vaccine supplies for use among disadvantaged children on influenza vaccination rates among children 6 months-18 years. Follow-up staff meetings and surveys were used to assess use and acceptability of the intervention strategies in the Intervention arm. Rates for the 2010-2011 and 2011-2012 influenza seasons were compared. Two-level generalized linear mixed modeling was used to evaluate outcomes. RESULTS: Overall increases in influenza vaccination rates were significantly greater in the Intervention arm (7.9 percentage points) compared with the Control arm (4.4 percentage points; P<0.034). These rate changes represent 4522 additional doses in the Intervention arm vs. 1390 additional doses in the Control arm. This effect of the intervention was observed despite the fact that rates increased significantly in both arms - 8/10 Intervention (all P<0.001) and 7/10 Control sites (P-values=0.04 to <0.001). Rates in two Intervention sites with pre-intervention vaccination rates >58% did not significantly increase. In regression analyses, a child's likelihood of being vaccinated was significantly higher with: younger age, white race (Odds ratio [OR]=1.29; 95% confidence interval [CI]=1.23-1.34), having commercial insurance (OR=1.30; 95%CI=1.25-1.35), higher pre-intervention practice vaccination rate (OR=1.25; 95%CI=1.16-1.34), and being in the Intervention arm (OR=1.23; 95%CI=1.01-1.50). Early delivery of influenza vaccine was rated by Intervention practices as an effective strategy for raising rates. CONCLUSIONS: Implementation of a multi-strategy toolkit and early vaccine supplies can significantly improve influenza vaccination rates among children in primary care practices but the effect may be less pronounced in practices with moderate to high existing vaccination rates. Clinical trial registry name/number: From Innovation to Solutions: Childhood Influenza/NCT01664793.

Shots by STFM: value of immunization software to family medicine residency directors: a CERA study.

BACKGROUND AND OBJECTIVES: The Group on Immunization Education (GIE) of the Society of Teachers of Family Medicine (STFM) has developed Shots by STFM immunization software, which is available free of charge for a variety of platforms. It is routinely updated with the Center for Disease Control and Prevention's (CDC's) most recent immunization schedules. Successful development and marketing of teaching resources requires periodic evaluation of their use and value to their target audience. This study was undertaken to evaluate the 2011 version of Shots by STFM. METHODS: Family medicine residency directors were surveyed about their use of Shots by STFM for teaching residents and their ratings of its features. RESULTS: The response rate for the survey was 38% (172/452). While awareness of Shots by STFM among responding residency directors was low (57%), ratings by those using the resource were excellent. Thirty percent of respondents recommend or require their residents to use Shots by STFM. CONCLUSIONS: Better marketing of Shots by STFM to family medicine residency directors seems to be indicated.

Keeping up-to-date with immunization practices.

This article presents sources of information for those in practice, administration, or education to stay up-to-date in vaccine recommendations. Web-based repositories predominate in the provision of information. Other sources include newsletters, conferences, journals, expert opinion, community organizations, and books. The promise of the electronic health record remains unfulfilled but improving.

An evaluation of immunization education resources by family medicine residency directors.

BACKGROUND AND OBJECTIVES: Immunization is a rapidly evolving field, and teachers of family medicine are responsible for ensuring that they and their students are knowledgeable about the latest vaccine recommendations. METHODS: A survey was mailed to 456 family medicine residency directors across the United States to obtain their evaluation of immunization resources developed by the Society of Teachers of Family Medicine's Group on Immunization Education. Frequencies, measures of central tendency, and differences between responses from 2001 to 2005 were analyzed. RESULTS: Directors of 261 (57%) family medicine residencies responded, with >80% reporting satisfaction with immunization teaching resources. The popularity of bound resources decreased from 2001 to 2005, while immunization Web sites increased in importance. The journal supplement, "Vaccines Across the Lifespan, 2005" was less frequently read in 2005 than its predecessor published in 2001, but quality ratings remained high. Use of the Web site, www.ImmunizationEd.org, and the Shots software for both desktop and handheld computers has increased since their creation. CONCLUSIONS: Electronic immunization teaching resources are increasingly popular among family medicine residencies. As the field continues to change, the use of electronic resources is expected to continue, since they are easily updated and, in the case of www.ImmunizationEd.org and Shots software, are available free of charge.

Impact of vaccine economic programs on physician referral of children to public vaccine clinics: a pre-post comparison.

BACKGROUND: The Vaccines for Children (VFC) Program is a major vaccine entitlement program with limited long-term evaluation. The objectives of this study are to evaluate the effect of VFC on physician reported referral of children to public health clinics and on doses administered in the public sector. METHODS: Minnesota and Pennsylvania primary care physicians (n = 164), completed surveys before (e.g., 1993) and after (2003) VFC, rating their likelihood on a scale of 0 (very unlikely) to 10 (very likely) of referring a child to the health department for immunization. RESULTS: The percentage of respondents likely to refer was 60% for an uninsured child, 14% for a child with Medicaid, and 3% for a child with insurance that pays for immunization. Half (55%) of the physicians who did not participate in VFC were likely to refer a Medicaid-insured child, as compared with 6% of those who participated (P < 0.001). Physician likelihood to refer an uninsured child for vaccination, measured on a scale of 0 to 10 where 10 is very likely, decreased by a mean difference of 1.9 (P < 0.001) from pre- to post-VFC. The likelihood to refer a Medicaid-insured child decreased by a mean of 1.2 (P = 0.001). CONCLUSION: Reported out-referral to public clinics decreased over time. In light of increasing immunizations rates, this suggests that more vaccines were being administered in private provider offices.

Tailored interventions to introduce influenza vaccination among 6- to 23-month-old children at inner-city health centers.

BACKGROUND: Because of high rates of hospitalization for influenza infections among very young children (< 2 years), the Advisory Committee on Immunization Practices initiated a new policy in 2002 that encouraged vaccination of healthy children aged 6 to 23 months against influenza. OBJECTIVE: To evaluate the effectiveness of implementing tailored interventions to introduce influenza vaccination of children 6 to 23 months of age in inner-city practices. STUDY DESIGN: A before-after trial with historical and concurrent controls was conducted in 6 health centers in low-income urban locations. METHODS: Intervention sites were selected, and interventions (directed at 1534 patients who were 6 to 23 months old) were implemented from a menu of strategies. Vaccination rates were measured from medical record reviews. Focus groups of nursing staffs provided evaluative information on strategies. RESULTS: Influenza vaccination rates improved significantly at the intervention health centers compared with the control center. Preintervention (2001-2002) rates ranged from 0% to 7.6%, and intervention (2002-2003) rates ranged from 15.2% to 49.2% (P < .001). The number of interventions ranged from 6 to 11. Sites that used more interventions (odds ratio, 1.24; 95% confidence interval, 1.15-1.34) and had staff support of the vaccination effort (odds ratio, 1.91; 95% confidence interval, 1.40-2.60) had higher vaccination rates. CONCLUSIONS: Tailored interventions resulted in successful introduction of influenza vaccination of 6- to 23-month-old children in inner-city health centers. More strategies and enthusiastic staff support may result in higher vaccination rates.

What predicts influenza vaccination status in older Americans over several years?

OBJECTIVES: To examine the correlates of repeat influenza vaccination and determine whether there are age-group (50-64, > or =65) differences in decision-making behavior. DESIGN: Longitudinal survey study. SETTING: Two community health centers in Pittsburgh, Pennsylvania. PARTICIPANTS: Two hundred fifty-three patients aged 50 and older in 2001 who visited one of the health centers and completed telephone surveys in 2002 and 2003 after the respective influenza seasons. MEASUREMENTS: Influenza vaccination status, demographic characteristics, and decision-making behavior were self-reported. Vaccination status was identified for three seasons: 2000-2001, 2001-2002, and 2002-2003. A three-level outcome was defined as unvaccinated all 3 years, vaccinated one to two times over 3 years, and vaccinated all 3 years. Factor analysis identified three decision-making behaviors. RESULTS: Predictors of being vaccinated across 3 years included being older, the belief that social forces influence vaccination behavior, and disagreement with the view that vaccine is detrimental. CONCLUSION: National educational efforts should be intensified to dispel the myths about alleged adverse events, including contracting influenza from inactivated influenza vaccine. Physicians should continue to share their personal experiences of treating patients with influenza, including the incidence of hospitalization and death.

Vaccine criticism on the World Wide Web.

BACKGROUND: The incidence of vaccine-preventable diseases is directly related to the number of unvaccinated children. Parents who refuse vaccination of their children frequently express concerns about vaccine safety. The Internet can influence perceptions about vaccines because it is the fastest growing source of consumer health information. However, few studies have analyzed vaccine criticism on the Web. OBJECTIVE: The purposes of this paper are to examine vaccine criticism on the Internet and to analyze the websites in order to identify common characteristics and ethical allegations. METHODS: A structured Web search was conducted for the terms "vaccine," "vaccination," "vaccinate," and "anti-vaccination" using a metasearch program that incorporated 8 search engines. This yielded 1138 Web pages representing 750 sites. Two researchers reviewed the sites for inclusion/exclusion criteria, resulting in 78 vaccine-critical sites, which were then abstracted for design, content, and allegations. RESULTS: The most common characteristic of vaccine-critical websites was the inclusion of statements linking vaccinations with specific adverse reactions, especially idiopathic chronic diseases such as multiple sclerosis, autism, and diabetes. Other common attributes (> or = 70% of websites) were links to other vaccine-critical websites; charges that vaccines contain contaminants, mercury, or "hot lots" that cause adverse events; claims that vaccines provide only temporary protection and that the diseases prevented are mild; appeals for responsible parenting through education and resisting the establishment; allegations of conspiracies and cover-ups to hide the truth about vaccine safety; and charges that civil liberties are violated through mandatory vaccination. CONCLUSIONS: Vaccine-critical websites frequently make serious allegations. With the burgeoning of the Internet as a health information source, an undiscerning or incompletely educated public may accept these claims and refuse vaccination of their children. As this occurs, the incidence of vaccine-preventable diseases can be expected to rise.

The 2002 United States varicella vaccine shortage and physician recommendations for vaccination.

BACKGROUND: The US experienced a shortage of varicella vaccine in 2002, leading to the concerns about its impact. METHODS: 204 Minnesota and Pennsylvania physicians, most (164) of whom were interviewed in 1999 on the topic of varicella vaccine, responded to a 2003 survey. RESULTS: Although 67% were aware of the 2002 varicella vaccine shortage, 24% experienced it and only 45% were aware of the 2002 temporary change in national vaccination recommendations. In response, more vaccinated until the supply was exhausted (59%) than postponed vaccination as recommended (41%). Most (91%) reported that the shortage did not change their likelihood of recommending vaccine. From 1999 to 2003, the percentage of physicians highly likely to recommend vaccination increased from 73% to 82% for children 12-18 months old (P < 0.01). In 2003, more physicians believed that it was likely for secondary skin infections to occur following varicella disease and for parents to request vaccination than in 1999 (P < 0.01). Almost all (93%) physicians in both years believed that serious side effects were unlikely. CONCLUSIONS: Over half of physicians were unaware of the change in vaccine recommendations due to the shortage and many did not follow that change, suggesting the need for a different strategy.

Immunization education among family practice residency programs.

BACKGROUND AND OBJECTIVES: The dynamic nature of immunization schedules, shortages, and administration techniques makes keeping up to date with current national recommendations difficult and necessitates periodic evaluation of immunization teaching resources. METHODS: This study surveyed family practice residency program directors in 1998 to assess their satisfaction with immunization teaching resources and interest in new resources. Subsequently, with funding from the Centers for Disease Control and Prevention, the Society of Teachers of Family Medicine Group on Immunization Education developed a series of educational materials devoted to educating family physicians about immunizations. In 2001, residency directors were surveyed again to evaluate the educational resources. RESULTS: Most program directors reported satisfaction with resources currently available to them for teaching residents about childhood immunizations, but about half (41% in 1998 versus 55% in 2001) agreed that keeping up to date on childhood immunizations was difficult. The corresponding figures for adult immunizations were 27% in 1998 and 36% in 2001. Pocket-size immunization schedules were ranked highly important (53% in 1998 versus 45% in 2001). Many would use handheld computer immunization schedules (53%). Although satisfaction with available resources did not increase following introduction of a newly developed journal supplement and Web site, the limited response received was favorable. CONCLUSIONS: Immunization teaching materials developed by family physicians, especially those that make use of evolving technologies, can be useful resources for individuals teaching family practice residents and for keeping up to date on recommendations for immunizations.